Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Tuesday, April 22, 2008

Sinking Fast

An article in today's paper incites a post, where none had been forthcoming. It's not news, really, in the sense that it's been well-known to many: us general surgeons are a dying breed. But it threatens to become very serious. There are many reasons, the mentioning of some of which could cause ire. The usual: doctors complaining about money and work. Sex, too.

It was just before I started training that California adopted a system for comparing one operation to another, payment-wise. Called the California Relative Value System (CRVS), and used or copied nationally, it purported to consider degree of difficulty, post-operative care, and, as I recall, a few other factors, in order to compare, say, a colon resection to a hernia repair; and, more interestingly, to a prostatectomy or hip replacement. Rumor had it that the general surgeon on the panel that came up with the scale was so busy he missed a lot of meetings. As a consequence, general surgery got screwed. The work of a colon resection was very unfavorably compared to that prostatectomy and pretty much everything else. The CRVS assigned "units:" if a hernia got, say, 11 units, (making that up; I don't recall the specifics and don't feel like looking it up), a colon resection got, say, 24. It was up to insurers, and medicaid, and medicare to assign dollars to units. Depending on who was paying, a unit might differ from institution to institution by many dollars; but the relative values were the same. The lowness (which translates to lowliness) of general surgical operations always annoyed me. The systems are different now, but the comparison remains: there are some quick outpatient eye operations, for example, that pay more than a Whipple procedure, which takes several hours, a boatload more skill, and requires many days of inpatient, and weeks of outpatient, care. Alas, poor me.

Add to the above the fact that emergency call for general surgeons can actually involve emergencies. This is, of course, true for other surgical specialties -- particularly orthopedics -- but in most communities there are fewer general surgeons than orthopods, so the frequency of call is greater. And the orthopedist fixes the bone and bolts (as it were); the general surgeon is left holding the bags. It's disruptive, it's hard, it's onerous. So it's not surprising that surgeons looking ahead, while looking back at the debt that trails them out of training, see options that are more remunerative and less demanding, and find the choice pretty clear. General surgery has its special attractions. No other field is as broad and deep. The variety of what we do is both rewarding and challenging; and the opportunity to have on-going relations with patients and families -- to be their "family surgeon" -- is something I cherished in my own practice. But there are limits... So, as we see in the initially-referenced article, the relative and actual numbers of general surgeons is heading down, dramatically. And there's another factor, not mentioned in the paper: girls.

I wrote recently about a trip I took back to UCSF, my training grounds, for a dinner honoring an old prof. Among the speakers was the chairperson of the surgery department, a very impressive and very talented woman. (Also, it was clear, a hell-raiser, in the best sense of the term.) With pride, she mentioned that for the first time the entire incoming group of surgery interns was female. The guest of honor, Senator Feinstein, seemed pleased. "Uh oh," was what I thought.

It's reality: women doctors are more likely to shorten careers for raising a family; or to seek opportunities for job-sharing; or to choose specialties which allow more flexibilty. One of my partners was a woman, and she quit entirely, and young, to be with her kids. The one hired after I left took several lengthy times off for maternity excursions. It's not that I object. I don't see any qualitative differences between boy surgeons and girl surgeons. It's just that it represents another -- and not-much-talked-about -- hole in the sinking ship of surgery. It will add to the shortage. Is all I'm saying.

You can't force people to become general surgeons (oh, I suppose you can, but I doubt it'd work out.) Solutions, if there are any, will be multi-faceted. Reimbursement inequities will need addressing. So will work hours. As I've said recently, the trend toward hospitalists might be a major boon; in fact, I don't see a solution that doesn't involve it. Meanwhile, look both ways when crossing the street, eat plenty of fiber, exercise, and don't swallow cherry pits.

The handful of women I know who are in med school all plan to balance their work goals with their family goals. These women are shaping their career paths from the front end to create room for both work and family . . . and consequently, they are not entering certain fields, including surgery. This is not because they are not qualified, or anything like that, but simply because it doesn't fit with their life plans.

So, I wonder, do the women who DO enter surgery programs tend to have different sets of priorities? Are they less likely to put work aside for a family? More likely to have stay-at-home husbands? More likely to try to "do it all"?

Maternity stats for women doctors (which presumably include a lot of people like my friends) may not be the same as stats for women surgeons, who may make different types of choices.

Patrick: hey, man, it's my blog. Don't demand accuracy. Seriously, I don't know of data specific to surgery. My general statement is true, I'm sure. As to surgeons, the point is not only that they may leave early; it's that they will choose other surgical fields, or arrange such things as job-sharing. Women still represent a significant minority of surgeons. My reaction to the announcement of an all-female incoming group was based on a prediction about the future.

You know the women surgeons I know--can I include the OB-Gyns--have worked full schedules even when pregnant. I was given some advice when I started my practice nearly 18 yrs ago by a female ENT (who is still in practice) to set my hours the way I wanted them. I have always refused (except for emergencies) to see scheduled patients after 4:30 pm. I will see them early, but I wanted to go home and "fix" dinner and have a family. I never managed to have babies of my own, but do occasionally make it to games, recitals, etc of my nieces and nephews. I have no plans to retire early. Neither do the female surgeons I know (breast surgeons, hand surgeons, ortho, ob-gyn, ENT, and me). I'm just as likely to answer that ER call as my male counterpart, though I will admit they are more likely to have longer (more extended) regular office hours.

It may be that I should have been a little more careful in writing this. I don't mean to detract from the main point: that there is a severe shortage of general surgeon on its way. The "female" thing, as a general trend, was perhaps ill-considered on my part: my person experience, in my clinic, has been as described. And I was surprised to hear that the entire intern group at my old training program was female. Whatever the impact of that might be, it's far less than the general picture of fewer people choosing general surgery, as the need continues to increase. See? I should have stuck to my sense of not having anything to say for now...

No, Dr Sid, you should not NOT have written the post. You are correct we have gotten side tracked. It is concerning that there may not be enough general surgeons (period) in the not so distant future. I wish more of the students could work with folks like you or Bongi or Buckeye who so obviously love the profession. It might engage that same love in the students/residents.

Thanks for a surplus post. I was researching health stuff today and saw somewhere that Hospitalists are the fastest growing medical position, with the # of positions expected to more than double w/in a few years. Among many other things, Dr. Schwab, you're a trend-setter to boot!

I actually think the surgeon shortage and link to women in the field can't really be separated out from each other. Of course, that may be because I'm in vet school, and of my class of 110 students, 15 are men. So, in veterinary medicine we're not only dealing with an upcoming general shortage (and existing shortage in equine and food animal medicine), but we're dealing with the issues Dr. Schwab mentions with differences in work preferences, habits, what have you, between men and women.

I do wonder though, how much of it is more of a GenXYer trend - I find we're not only more inclined to strive for a better work life balance, but we're actively encouraged to do so by our faculty.

Another issue is pay disparity. If we know that as women we're going to be paid less than our male counterparts for the same work, experience, and expertise (and the AVMA stats on that are astounding), then why should we be willing to put in the old school hours?

I was just at a recent meeting of Program Directors of general surgery residencies and this was a very hot topic. 70% of graduating gen surg chiefs go into fellowship. Given that the average med student finishes with nearly $200,000 of debt, it's hard to imagine many being interested in doing night call, taking care of disasters, and not getting paid much when they could go into Plastics and then Hand and do nice outpatient carpal tunnel releases during normal hours while making more than the guys doing emergency colostomies on perf'd tics at 3AM.

Unfortunately, I think it all does come down to money, but until a major crisis happens (developing but not really major for a few more years), nothing will actually change.

It's a frustrating time to be a young general surgeon.

My friend who is a plastic surgeon in Long Island gets paid 5 times more to sew up a laceration than I do as a general surgeon. Why? Very simply, he is non par with insurance companies and people are willing to pay for a presumed better cosmetic result. Somehow, when your appendix bursts, it's a different story.

I'll preface this by saying that the best surgeon in my residency class was a woman. She's now doing transplant surgery at a top academic center. But I do believe most women have a natural desire to have children and raise a family. That means less time in the hospital and part-time employement situations. The way general surgery was originally set up was not condusive to such a balancing act. But now we see a gradual erosion of the classic concept of the "general surgeon", especially when you consider the long term effects of the 80 hour work week down the line. The softening of surgery may be a good thing longterm; I don't know. But it has certainly made it a more appealing career choice for talented female medical students.

I won't touch the "females in surgery" subject except to point out that in 10 years of private practice, I've had contact with four female surgeons, either in my practice, a competing practice or my Dad's practice (in another city). So far the scorecard is one still working full-time, one working part-time and one who has quit practice altogether (all post-child bearing), with one currently out on maternity leave and planning to continue full-time.

Sid, I was wondering when you'd post on this topic (the general surgeon shortage, that is). For the last several months, it seems like every issue of every surgical journal and throw-away I've seen has had an article on the developing shortage. Only recently does the topic seem to be appearing in the mainstream media.

I don't know if the hospitalist concept is the answer, but the pool of potential surgeons certainly seems to be shrinking, and I don't see any likelihood that it's going to change anytime soon. Besides the residents who branch off into fellowships in other fields (Plastics, CT, etc.), there also seems to be increasing subspecialization within General Surgery itself. If a surgeon completes a fellowship in breast surgery and focuses his practice accordingly, is he likely to want to take general call and find himself dealing with intra-abdominal emergencies when he doesn't work there as part of his normal routine? Same with the vascular specialists.

I'm not optimistic that it'll get better. The politicians talk a lot about improving access to healthcare. So far I haven't really heard any of the candidates address whether there will be enough people to provide that healthcare once everyone gains access.

To the extent that the hospitalist model is part of the solution, I meant it in terms of making the life of the "office-based" surgeon less onerous and therefore more attractive to future docs; and in terms of providing people who'll take those emergency cases, lessening the issue of the breast surgeon taking care of the perforated tic. Whether there'd be enough people interested in becoming hospitalist/surgeons remains to be seen. Some, of course, see a future of "centers of excellence" (about which I expressed a cynical view a while back), such that you'll take your breast to Omaha, your gallbladder to Newark; who knows: maybe eventually your left breast to Omaha and your right one to Cleveland.

So what about male surgeons? I mean, Sid seems to have left practice before retirement age? He talks about being conflicted about that decision himself.

People here seem to see Sid's decision as an individual decision, and any woman's decision as a generalized problem. But each woman's decision is as individual as Sid's.

Some women DO make work choices that mean they work less time, or retire earlier, or whatever.

But, in relationships with two straights married, how many men really share 50% of household/family work? How many men take 50% of the responsibility for raising children (either at all, or after they're done nursing)?

Women bear the brunt of household and family work because we live in a patriarchal, sexist society which is organized so that women do that work. Maybe it's time to question why men aren't doing their share, rather than blaming women?

bardiac: first, I worked well into my sixth decade. Second, I quit from over-work, having literally done twice as much as my partners (including a woman) for a long time, and twice as much as the average for surgeons in the US. Third, I was not "blaming" women for anything. I was stating what seems to be reality. It was not my intention to color it in any way; it just happens to be true. I don't disagree at all that women bear more than their share of family life. If there weren't a present and future surgeon shortage I'd not have written this at all.

Sid, sorry, you weren't blaming women. I shouldn't have implied that you were (while stating it as a generalization). Women are often blamed, but you weren't doing it.

I wasn't criticizing your decision to cut back on working, but noting that your decision is treated as an individual decision, while women's decisions aren't. The women who quit after working full time, keeping a house, raising kids, are also quitting because they're doing double work.

The solution to the future problem is to find ways to split work more equitably. It's not easy.

I know the female surgeon thing is a bit of a non sequitur but my two cents are very simple.

Excluding ob-gyn, it's roughly 18% of surgical residents (registrars) are are women. At the end of the day, the surgeon that chooses to honour her commitments to her family is the woman that misses out on the fellowship or retires early. It's not open to judgement, it's merely a personal decision.

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.